GW1-2022-10361_Well Construction - GW1_20221115

WELL C®NSTRU&ION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.0A Pei d- �Ta 1,ry U/��. FR0,11ATER WATER-ZONES
DESCRIPTION
Well Contractor Name., a 8o ft ' lft• 2 Q
63 8-
NC Well Contractor Certification Number IS.OUTER CASING_for multi-cased svells OR LINER if a ricable -
/ FROM TO DIAMETER THICMNESS MATERIAL.
Alt, 1t 'e L. �r 1 n ft. 5 ft v in. ��P �, U.
Company Name J 16.INNER CASING OR-TUBING geothermal closed-loo .-
!!�� �7 © FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: •<2k A / a ft. ft.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) ❑Residential Water SuPP1Y(single) ft. ft.
❑Industrial/Commercial [ idential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Itri ation Q ft- �0 ft• W 6" e
Non-Water Supply Well: d e
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAVEL`.PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM
it. To rt. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG a tack additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FFTO DESCRIPTION(color•hardness,soil/rock e, rain size,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) tadft 116Gum4.Date Well(s)Completed: Cl— + lab ft.60, fr.5.Well Location: 60 fL e
l 07,'c iA h 5'fl N C Gu►�Z�'� 66 ft. b it. S
Facility/Owner Name Facility
IID#(if applicable)
n
l0 l 12 Any 1 e l'�r !l tip d I L— ft ft
�,
Physical Address,City,and Zip 21.REMARKS'
�^"6;
U/UraIL) 0(i ;zy6611 NO V 1 ,-
County Parcel Identification No.(PIN) "
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: �+:?1�,;�7�;
(ifwell field,one lat/long is sufficient)
3 TO 'y 116 N CPO 3 5. a 7- /0 w , -A/z; - -�Z
�� S' tare of Certified WeIrContractbr Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I herebv certify that the ivell(s)was(+vere)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or L+slVo copy of this record has been provided to the well owner.
lfthis is a repair,fill out Brown well construction information and explain the nature ofthe
repair under#21 ren:arFs section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total'well depth below land surface• (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdieretu(erample-3 @200'and29MI construction to the following:
e 10.Static water level below top of casing: 7 O (ft.) Division of Water Quality,Information Processing Unit,
lj'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: (� �� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(i.e.auger mtury, able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Q n 13a.Yield(gpm)-----/ Method of test: 24c.For Water SuPT31y&Geothermal Wells: In addition to sending the form to
! (1/t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ,A s completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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